Application for Federal Assistance (SF-424) (PDF)
Application for Federal Assistance (SF-424) (PDF)
Application for Federal Assistance (SF-424) (PDF)
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* 1. Type of Submission:<br />
Preapplication<br />
<strong>Application</strong><br />
Changed/Corrected <strong>Application</strong><br />
* 2. Type of <strong>Application</strong>: * If Revision, select appropriate letter(s):<br />
New<br />
Continuation<br />
Revision<br />
* 3. Date Received: 4. Applicant Identifier:<br />
* Other (Specify)<br />
5a. <strong>Federal</strong> Entity Identifier: * 5b. <strong>Federal</strong> Award Identifier:<br />
State Use Only:<br />
6. Date Received by State: 7. State <strong>Application</strong> Identifier:<br />
8. APPLICANT INFORMATION:<br />
* a. Legal Name:<br />
* b. Employer/Taxpayer Identification Number (EIN/TIN): * c. Organizational DUNS:<br />
d. Address:<br />
* Street1:<br />
Street2:<br />
* City:<br />
County:<br />
* State:<br />
Province:<br />
* Country:<br />
* Zip / Postal Code:<br />
e. Organizational Unit:<br />
Department Name: Division Name:<br />
USA: UNITED STATES<br />
f. Name and contact in<strong>for</strong>mation of person to be contacted on matters involving this application:<br />
Prefix: * First Name:<br />
Middle Name:<br />
* Last Name:<br />
Suffix:<br />
Title:<br />
<strong>Application</strong> <strong>for</strong> <strong>Federal</strong> <strong>Assistance</strong> <strong>SF</strong>-<strong>424</strong><br />
Organizational Affiliation:<br />
* Telephone Number: Fax Number:<br />
* Email:<br />
OMB Number: 4040-0004<br />
Expiration Date: 03/31/2012
<strong>Application</strong> <strong>for</strong> <strong>Federal</strong> <strong>Assistance</strong> <strong>SF</strong>-<strong>424</strong><br />
9. Type of Applicant 1: Select Applicant Type:<br />
Type of Applicant 2: Select Applicant Type:<br />
Type of Applicant 3: Select Applicant Type:<br />
* Other (specify):<br />
* 10. Name of <strong>Federal</strong> Agency:<br />
11. Catalog of <strong>Federal</strong> Domestic <strong>Assistance</strong> Number:<br />
CFDA Title:<br />
* 12. Funding Opportunity Number:<br />
* Title:<br />
13. Competition Identification Number:<br />
Title:<br />
14. Areas Affected by Project (Cities, Counties, States, etc.):<br />
* 15. Descriptive Title of Applicant's Project:<br />
Attach supporting documents as specified in agency instructions.
<strong>Application</strong> <strong>for</strong> <strong>Federal</strong> <strong>Assistance</strong> <strong>SF</strong>-<strong>424</strong><br />
16. Congressional Districts Of:<br />
* a. Applicant * b. Program/Project<br />
Attach an additional list of Program/Project Congressional Districts if needed.<br />
17. Proposed Project:<br />
* a. Start Date: * b. End Date:<br />
18. Estimated Funding ($):<br />
* a. <strong>Federal</strong><br />
* b. Applicant<br />
* c. State<br />
* d. Local<br />
* e. Other<br />
* f. Program Income<br />
* g. TOTAL<br />
* 19. Is <strong>Application</strong> Subject to Review By State Under Executive Order 12372 Process?<br />
a. This application was made available to the State under the Executive Order 12372 Process <strong>for</strong> review on<br />
b. Program is subject to E.O. 12372 but has not been selected by the State <strong>for</strong> review.<br />
c. Program is not covered by E.O. 12372.<br />
* 20. Is the Applicant Delinquent On Any <strong>Federal</strong> Debt? (If "Yes", provide explanation.) Applicant <strong>Federal</strong> Debt Delinquency Explanation<br />
Yes No<br />
21. *By signing this application, I certify (1) to the statements contained in the list of certifications** and (2) that the statements<br />
herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances** and agree to<br />
comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may<br />
subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 218, Section 1001)<br />
** I AGREE<br />
** The list of certifications and assurances, or an internet site where you may obtain this list, is contained in the announcement or agency<br />
specific instructions.<br />
Authorized Representative:<br />
Prefix: * First Name:<br />
Middle Name:<br />
* Last Name:<br />
Suffix:<br />
* Title:<br />
* Telephone Number: Fax Number:<br />
* Email:<br />
* Signature of Authorized Representative: * Date Signed:<br />
.
<strong>Application</strong> <strong>for</strong> <strong>Federal</strong> <strong>Assistance</strong> <strong>SF</strong>-<strong>424</strong><br />
* Applicant <strong>Federal</strong> Debt Delinquency Explanation<br />
The following field should contain an explanation if the Applicant organization is delinquent on any <strong>Federal</strong> Debt. Maximum number of<br />
characters that can be entered is 4,000. Try and avoid extra spaces and carriage returns to maximize the availability of space.
Item: Entry:<br />
1. Type of Submission: (Required): Select one type of submission in accordance with agency<br />
instructions.<br />
• Pre‐application<br />
• <strong>Application</strong><br />
• Changed/Corrected <strong>Application</strong> – If requested by the agency, check if this submission<br />
is to change or correct a previously submitted application. Unless requested by the<br />
agency, applicants may not use this to submit changes after the closing date.<br />
2. Type of <strong>Application</strong>: (Required) Select one type of application in accordance with agency<br />
instructions.<br />
• New – An application that is being submitted to an agency <strong>for</strong> the first time.<br />
• Continuation ‐An extension <strong>for</strong> an additional funding/budget period <strong>for</strong> a project<br />
with a projected completion date. This can include renewals.<br />
• Revision ‐Any change in the <strong>Federal</strong> Government’s financial obligation or<br />
contingent liability from an existing obligation. If a revision, enter the appropriate<br />
letter(s). More than one may be selected. If "Other" is selected, please specify in<br />
text box provided.<br />
A. Increase Award<br />
B. Decrease Award<br />
C. Increase Duration<br />
D. Decrease Duration<br />
E. Other (specify)<br />
3. Date Received: Leave this field blank. This date will be assigned by the <strong>Federal</strong> agency.<br />
4. Applicant Identifier: Enter the entity identifier assigned buy the <strong>Federal</strong> agency, if any, or the<br />
applicant’s control number if applicable.<br />
5a. <strong>Federal</strong> Entity Identifier: Enter the number assigned to your organization by the <strong>Federal</strong><br />
Agency, if any.<br />
5b. <strong>Federal</strong> Award Identifier: For new applications leave blank. For a continuation or revision to an<br />
existing award, enter the previously assigned <strong>Federal</strong> award identifier number. If a<br />
changed/corrected application, enter the <strong>Federal</strong> Identifier in accordance with agency<br />
instructions.<br />
6. Date Received by State: Leave this field blank. This date will be assigned by the State, if<br />
applicable.<br />
7. State <strong>Application</strong> Identifier: Leave this field blank. This identifier will be assigned by the State,<br />
if applicable.<br />
8. Applicant In<strong>for</strong>mation: Enter the following in accordance with agency instructions:<br />
a. Legal Name: (Required): Enter the legal name of applicant that will undertake the<br />
assistance activity. This is that the organization has registered with the Central<br />
Contractor Registry. In<strong>for</strong>mation on registering with CCR may be obtained by visiting<br />
the Grants.gov website.<br />
b. Employer/Taxpayer Number (EIN/TIN): (Required): Enter the Employer or Taxpayer<br />
Identification Number (EIN or TIN) as assigned by the Internal Revenue Service. If your
organization is not in the US, enter 44‐4444444.<br />
c. Organizational DUNS: (Required) Enter the organization’s DUNS or DUNS+4 number<br />
received from Dun and Bradstreet. In<strong>for</strong>mation on obtaining a DUNS number may be<br />
obtained by visiting the Grants.gov website.<br />
d. Address: Enter the complete address as follows: Street address (Line 1 required), City<br />
(Required), County, State (Required, if country is US), Province, Country (Required),<br />
Zip/Postal Code (Required, if country is US).<br />
e. Organizational Unit: Enter the name of the primary organizational unit (and<br />
department or division, (if applicable) that will undertake the assistance activity, if<br />
applicable.<br />
f. Name and contact in<strong>for</strong>mation of person to be contacted on matters involving this<br />
applicant required), organizational affiliation (if affiliated with an organization other<br />
on: Enter the name (First and last name than the applicant organization), telephone<br />
number (Required), fax number, and email address (Required) of the person to contact<br />
on matters related to this application.<br />
9. Type of Applicant: (Required) Select up to three applicant type(s) in accordance with agency<br />
instructions.<br />
A. State Government<br />
B. County Government<br />
C. City or Township Government<br />
D. Special District Government<br />
E. Regional Organization<br />
F. U.S. Territory or Possession<br />
G. Independent School District<br />
H. Public/State Controlled Institution of Higher Education<br />
I. Indian/Native American Tribal Government (<strong>Federal</strong>ly Recognized)<br />
J. Indian/Native American Tribal Government (Other than <strong>Federal</strong>ly Recognized)<br />
K. Indian/Native American Tribally Designated Organization<br />
L. Public/Indian Housing Authority<br />
M. Nonprofit<br />
N. Nonprofit<br />
O. Private Institution of Higher Education<br />
P. Individual<br />
Q. For‐Profit Organization (Other than Small Business)<br />
R. Small Business<br />
S. Hispanic‐serving Institution<br />
T. Historically Black Colleges and Universities (HBCUs)<br />
U. Tribally Controlled Colleges and Universities (TCCUs)<br />
V. Alaska Native and Native Hawaiian Serving Institutions<br />
W. Non‐domestic (non‐US) Entity<br />
X. Other (specify)<br />
10. Name Of <strong>Federal</strong> Agency: (Required) Enter the name of the <strong>Federal</strong> agency from which<br />
assistance is being requested with this application.<br />
11. Catalog Of <strong>Federal</strong> Domestic <strong>Assistance</strong> Number/Title: Enter the Catalog of <strong>Federal</strong> Domestic<br />
<strong>Assistance</strong> number and title of the program under which assistance is requested, as found in<br />
the program announcement, if applicable.<br />
12. Funding Opportunity Number/Title: (Required) Enter the Funding Opportunity Number and
title of the opportunity under which assistance is requested, as found in the program<br />
announcement.<br />
13. Competition Identification Number/Title: Enter the Competition Identification Number and<br />
title of the competition under which assistance is requested, if applicable.<br />
C. Increase Duration D. Decrease Duration E. Other (specify)<br />
14. Areas Affected By Project: List the areas or entities using the categories (e.g., cities, counties,<br />
states, etc.) specified in agency instructions. Use the continuation sheet to enter additional<br />
areas, if needed.<br />
15. Descriptive Title of Applicant’s Project: (Required) Enter a brief descriptive title of the project.<br />
If appropriate, attach a map showing project location (e.g., construction or real property<br />
projects). For pre‐applications, attach a summary description of the project.<br />
16. Congressional Districts Of: (Required) 16a. Enter the applicant’s Congressional District, and<br />
16b. Enter all District(s) affected by the program or project. Enter in the <strong>for</strong>mat: 2 characters<br />
State Abbreviation – 3 characters District Number, e.g., CA‐005 <strong>for</strong> Cali<strong>for</strong>nia 5th district, CA012<br />
<strong>for</strong> Cali<strong>for</strong>nia 12th district, NC‐103 <strong>for</strong> North Carolina’s 103rd district. • If all congressional<br />
districts in a state are affected, enter “all” <strong>for</strong> the district number, e.g., MD‐all <strong>for</strong> all<br />
congressional districts in Maryland. • If nationwide, i.e. all districts within all states are<br />
affected, enter US‐all. • If the program/project is outside the US, enter 00‐000.<br />
17. Proposed Project Start and End Dates: (Required) Enter the proposed start date and end date<br />
of the project.<br />
18. Estimated Funding: (Required) Enter the amount requested or to be contributed during the<br />
first funding/budget period by each contributor. Value of in‐kind contributions should be<br />
included on appropriate lines, as applicable. If the action will result in a dollar change to an<br />
existing award, indicate only the amount of the change. For decreases, enclose the amounts in<br />
parentheses.<br />
19. Is <strong>Application</strong> Subject to Review by State Under Executive Order 12372 Process? Applicants<br />
should contact the State Single Point of Contact (SPOC) <strong>for</strong> <strong>Federal</strong> Executive Order 12372 to<br />
determine whether the application is subject to the State intergovernmental review process.<br />
Select the appropriate box. If “a.” is selected, enter the date the application was submitted to<br />
the State.<br />
20. Is the Applicant Delinquent on any <strong>Federal</strong> Debt? (Required) Select the appropriate box. This<br />
question applies to the applicant organization, not the person who signs as the authorized<br />
representative. Categories of debt include: But may not be limited to; delinquent<br />
audit disallowances, loans and taxes. If yes, include an explanation in an attachement.<br />
21. Authorized Representative: (Required) To be signed and dated by the authorized<br />
representative of the applicant organization. Enter the name (First and last name required) title<br />
(Required), telephone number (Required), fax number, and email address (Required) of the<br />
person authorized to sign <strong>for</strong> the applicant. A copy of the governing body’s authorization <strong>for</strong><br />
you to sign this application as the official representative must be on file in the applicant’s<br />
office. (Certain <strong>Federal</strong> agencies may require that this authorization be submitted as part of the<br />
application.)